30-31 - PRESCRIBING: A nation prescribed

Data can tell interesting stories, and I’ve seen a few when working on Wilmington’s latest insight compendium, State of the Nation.

The review covers hospital episode statistics, demographics and inequalities, performance, therapy area analysis and workforce, among other fields.

For now, it’s the prescribing data I want to explore.

Figures from the past few months are in and the trends are clear – hospital prescribing is providing the biggest area of growth in spending; there’s wide variation in how much different integrated care systems spend on drugs per head. Diabetes, anticoagulant and respiratory drugs are driving growth in primary care, whereas in secondary care it’s all about oncology and immunology biologics.

In this article we’ll take a closer look at five different data sets to see what going on in these critical areas.

1. Spend on secondary care (hospital) prescribing accelerated in 2021/22
Total prescribing costs in England have increased by £2.7 billion between 2017/18 and 2021/22, representing compound annual growth of 4.3% over these five years.

Much of this increase has come from growing spend within secondary care/hospital prescribing, which increased by £2.1 billion between 2017/18 and 2021/22. There was a particularly noteworthy increase in the latest 12 months, with hospital prescribing costs increasing by £1.3 billion between 2020/21 and 2021/22 alone.

As a result, hospital prescribing now accounts for 49.3% of all prescribing spend, having accounted for 44.1% of prescribing spend in 2017/18.

Primary care prescribing costs were relatively flat by comparison, growing by £635 million between 2017/18 and 2021/22, as the continued use of generic medicine has helped to contain spend on primary care medicines.

Conversely, spend within hospital prescribing has continued to grow apace as the availability of innovative, specialty treatments for diseases with high unmet need continues to grow.

2. Disparity remains in prescribing costs per capita across integrated care systems
There is considerable local variation in prescribing spend per capita, with some integrated care boards (ICB) exhibiting much higher prescribing spend per population.

Birmingham & Solihull ICB, North Central London ICB, Cambridgeshire & Peterborough ICB and South East London ICB were the outliers in this regard, all spending more than £400 per capita on prescribing in 2021/22.

While some integrated care systems, such as Hertfordshire & West Essex ICB, South West London ICB, Bedfordshire, Luton & Milton Keynes ICB and Northamptonshire ICB recorded per capita prescribing spend less than £250.

The average prescribing costs per capita were £316 across all ICBs in 2021/22.
It’s clear some systems are spending well above the average, and some systems well below the average on prescribing.

3. Diabetes medicine, anticoagulants and respiratory top primary care prescribing sections
The largest area of expenditure within primary care prescribing in 2021/22 was diabetes with a spend of over £1.2 billion and annual growth of 4.9%.

Anticoagulant prescribing was over £800 million and had growth of 8.8%, while steroids used in respiratory accounted for costs of more than £600 million. Following a noteworthy increase in uptake during the pandemic, spending on antidepressant prescribing shrank back to pre-pandemic levels, decreasing 34.0% year-on-year to £247 million in 2021/22.

Pain medicine (analgesics), oral nutrition, antiepileptics, bronchodilators and hypertension/heart failure medicine made up the other largest areas of spend within primary care.

4. Biologic treatments in oncology and immunology continue to drive secondary care prescribing
Analysis of the leading secondary care medicines based on cost reveals a much higher proportion of high-cost drugs with annual costs exceeding £100m than is seen within primary care prescribing.

As we have seen, the growing use of specialty medicines within secondary care is driving up overall spend on hospital prescribing. Although based on indicative cost and therefore not taking into account any discounting that takes place, the leading secondary care medicine remained adalimumab in 2021/22, with costs increasing 15.0% to £660m.

Biologic treatments such as monoclonal antibody therapies made up a large portion of the leading secondary care medicines on cost, as they continue to be a mainstay of treatment within oncology, immunology and other areas of high unmet need. Spend on innovative cystic fibrosis treatments has also grown significantly.

5. Cytotoxic drugs incur the biggest costs within secondary care
Analysis of secondary care prescribing by section reveals cytotoxic drugs to be the largest area of expenditure

With spend on this group of cancer therapeutics reaching nearly £2 billion in 2021/22, this was a considerable margin ahead of the next highest sections, immunology treatments, which accounted for costs of almost £800m in 2021/22, and rheumatic disease medicines, which accounted for costs of £714m in the latest financial year.

Both cytotoxic drugs and drugs affecting the immune system saw double-digit growth year-on-year, while mucolytics, which incurred the fourth highest costs at £564 million, grew sharply at 35.9% year-on-year as highly innovative treatments for cystic fibrosis continued to transform the lives of patients.

The final analysis
While the NHS continues to push for care closer to home and patient-centric pathways, the service is still leaning heavily on secondary care drugs prescribing – mainly initiated by specialists – to manage patients, particularly those with LTCs.

At a recent Wilmington Healthcare roundtable, medicines optimisation leads from around the country were keen to stress that the setting should not be driving the treatment, and there could be much more cohesion and communication between sectors.

Why should secondary care always incur these costs – and why can’t primary and community care be enabled to do more, under shared care guidelines, or flexibility on ‘red’/secondary care only drug status?

And it’s clear there’s still wide local variation in medicines spend per patient. Why should this be, when – in theory at least – the drug should cost the same around the country and is backed by the same evidence base?

It’s essential that industry looks at the pathway – higher costing drugs can create better overall outcomes for the system, and reduce the burden on secondary care by managing complex patients out of hospital, as well as better clinical outcomes for the patient.

The other learning is that each system is its own health economy; why certain patient groups are costing more in some ICSs rather than others is a mystery to be explored; in the big spending ones, are they using the treatment pathway most effectively?

And in the ones spending less – is it because they haven’t uncovered the patients yet?